The impact of an operation and management intervention on toilet usability in schools in the Philippines: a cluster randomised controlled trial.

BACKGROUND: Access to usable water, sanitation and hygiene provision in schools is included within indicators in the Sustainable Development Goals. Progress towards these indicators is dependent on developing an understanding of which intervention components are most effective to operate and maintain usable services. This study aimed to determine the impact of a school toilet operation and management intervention in the Philippines on toilet usability and student and teacher satisfaction, adjusted for clustering at school level. METHODS: In a non-blinded cluster randomised controlled trial, we compared improvements in usability and cleanliness of school toilets among those schools receiving a low-cost, replicable intervention. Toilet usability was measured based on Sustainable Development Goal indicators related to school sanitation defined by the UNICEF/WHO Joint Monitoring Programme for Water, Sanitation and Hygiene. Intervention schools received consumables, support kits, and structured tools designed to facilitate operation and maintenance of sanitation facilities. The primary outcome, toilet usability and cleanliness, was compared through a difference-in-difference analysis of toilet usability. Secondary outcomes of student and teacher satisfaction were measured through a survey at endline. All outcomes were adjusted for clustering at school level. RESULTS: 20 eligible schools in the Batangas region of the Philippines were randomly selected and allocated to either control or intervention group. We found that non-classroom toilets were 48% more likely to meet quality benchmarks in intervention schools, but this was not statistically significant. When including in-classroom toilets in the analysis, there were no significant differences in toilet usability - defined as accessible, functional, private and of high quality - between intervention and control schools. When stratified by toilet location, children in the intervention group clusters expressed a minor, but statistically significant increase in overall satisfaction with sanitation facilities (p = 0.035). CONCLUSION: Water, sanitation and hygiene interventions in schools focusing on operation and maintenance showed potential to improve toilet usability, but universal achievement of SDG targets may require additional efforts addressing toilet infrastructure. TRIAL REGISTRATION: ClinicalTrials.gov NCT03204175, June 2017 prior to participant enrolment

The role of psychological distress in the relationship of financial strain with oral health and dental attendance in Dutch adults:A mediation analysis based on cross-sectional data

Objectives: The study aimed to assess whether psychological distress mediates the association between financial strain and oral health and dental attendance in the Dutch adult population.Methods: The study followed a cross-sectional design based on 2812 participants from the 2014 wave of the Dutch population-based GLOBE study. Financial strain was considered the exposure, while psychological distress measured with the Mental Health Inventory-5 (MHI-5) was the mediator. The outcomes included self-reported number of teeth, self-rated oral health, and self-reported dental attendance. Generalized regression analyses were used for the mediation analysis adjusted for several covariables. Results: Greater financial strain was significantly associated with poorer self-rated oral health (total effect: 0.09, 95%CI: 0.05; 0.14) and restorative or no dental attendance (i.e. participants never visiting a dentist or only visiting a dentist for regular treatments or when they have complaints with their mouth, teeth, or prosthesis) (total effect: 0.05, 95%CI: 0.02; 0.09). Greater financial strain was not significantly associated with self-reported number of teeth (total effect: −0.14, 95%CI: −0.91; 0.64). Psychological distress significantly mediated the association of financial strain with self-rated oral health (average causal mediation effect [ACME]: 0.02, 95%CI: 0.01; 0.03) and self-reported dental attendance (ACME: 0.01, 95%CI: 0.00; 0.02), respectively. However, it did not significantly mediate the association of financial strain with self-reported number of teeth (ACME: −0.11, 95%CI: −0.25; 0.02). The estimated proportion of the total effect of financial strain on self-rated oral health and self-reported dental attendance that could be explained by psychological distress was respectively 24% (95%CI: 14%; 48%) and 19% (95%CI: 6%; 62%). Conclusions: Psychological distress partly explains the association of financial strain with self-rated oral health and dental attendance, but not with self-reported number of teeth. Future studies using longitudinal data are necessary to confirm the results.</p

Academic detailing in oral healthcare - results of the ADVOCATE Field Studies

Background: Academic detailing (AD) is a defined form of educational outreach that can be used to influence decision making and reduce unwarranted variation in healthcare delivery. This paper describes the results of the proof of concept phase of the ADVOCATE Field Studies. This study evaluated the feasibility, acceptability and usefulness of AD reinforced with feedback data, to promote prevention-oriented, patient-centred and evidence-based oral healthcare delivery by general dental practitioners (GDPs). Methods: In the Field Studies, six groups of GDPs (n = 39) were recruited in The Netherlands, Germany and Denmark. Each group had four meetings reinforced with feedback data for open discussions on dental practice and healthcare delivery. Conventional and directed content analysis was used to analyze the qualitative data collected from focus group interviews, debriefing interviews, field notes and evaluation forms. Results: A total of nine themes were identified. Seven themes related to the process of the Field Studies and covered experiences, barriers and facilitators to AD group meetings, data collection and the use of an electronic dashboard for data presentation and storage. Two themes related to the outcomes of the study, describing how GDPs perceived they made changes to their clinical practice as a result of the Field Studies. Conclusions: The ADVOCATE Field Studies approach offers a novel way of collecting and providing feedback to care providers which has the potential to reduce variation oral healthcare delivery. AD plus feedback data is a useful, feasible approach which creates awareness and gives insight into care delivery processes. Some logistic and technical barriers to adoption were identified, which if resolved would further improve the approach and likely increase the acceptability amongst GDPs

Impact of a school-based water, sanitation and hygiene programme on children's independent handwashing and toothbrushing habits: a cluster-randomised trial.

OBJECTIVES: To explore whether a school-based water, sanitation and hygiene programme, which includes group hygiene activities, contributes to the formation of independent handwashing and toothbrushing habits among Filipino children. METHODS: In this cluster-randomised trial, twenty primary schools were randomly allocated to the intervention or control arm. Intervention schools received group handwashing facilities and implemented daily group handwashing and toothbrushing activities. A soap use to toilet event ratio was calculated to measure children's independent handwashing behaviour after toilet use, and dental plaque accumulation on Monday morning was measured as a proxy indicator for children's independent toothbrushing behaviour at home. RESULTS: Four months after implementation, handwashing and toothbrushing behaviours did not significantly differ between intervention and control schools. The mean soap use in intervention schools and control schools was 0.41 g and 0.30 g per toilet event, respectively (p = 0.637). Compared to baseline, mean plaque scores reduced by 4.2% and 3.5% in intervention and control schools, respectively (p = 0.857). CONCLUSIONS: Although health benefits have been established, school-based group handwashing and toothbrushing may not be sufficient to increase children's uptake of independent hygiene behaviours

Material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities in oral health

Background: This study aimed to assess the contribution of material, behavioural, cultural and psychosocial factors in the explanation of socioeconomic inequalities (education and income) in oral health of Dutch adults. Methods: Cross-sectional data from participants (25-75 year

Perspectives of general dental practitioners on preventive, patient-centred, and evidence-based oral healthcare

Objective In the last 30 years, innovations in oral healthcare (OHC), such as advanced restorative techniques, shifts towards preventive and evidence-based care and changes in patients’ expectations, have increased the complexity of clinical decision-making in OHC. Little is known about the perspectives of general dental practitioners (GDPs) on the value of providing preventive, patient-centred and evidence-based OHC. This study aimed to explore the range of perspectives present amongst GDPs on OHC. Method Q-methodology was used to explore perspectives among 78 GDPs working in the Netherlands. Participants were asked to sort 50 statements representing three central domains in OHC: i.) restorative versus preventative OHC, ii.) disease-centred versus patient-centred OHC and iii.) expertise-based versus evidence-based OHC. Opinion statements about delivering OHC were formulated on the basis of published literat

Association of integration with oral health among Indian migrants living in the Netherlands.

BackgroundLimited data exist about the relationship between acculturation and oral health. Hence, the aim of this study was to assess the association of integration with self-reported oral health, behaviours, and oral healthcare utilization among Indian migrants living in the Netherlands, a cross sectional survey study.MethodsBetween February and April 2021, a random sample from Dutch municipalities was obtained for the Indian migrants living in the Netherlands (n = 147). A validated questionnaire was used to collect information on independent variables, namely socio-demographic, integration assessment tool: Immigration Policy Lab (IPL-12) and everyday discrimination scale (EDS). The outcome variables were self-reported oral health, oral health behaviours, and oral healthcare utilization. Multiple regression analysis was used to assess the associations.ResultsHigher integration among Indian migrants was associated with longer stay in the Netherlands, having a Dutch passport, intention to settle in the Netherlands, and having a permanent residence. After adjusting for covariates such as age, gender, marital status, education, income, occupation, and dental insurance, regression analysis showed that Indians with higher integration had lower odds of reporting their oral health as fair to poor [OR = 0.92(95%CI:0.0.85;0.99)] than the Indians with low integration scores. Also, Indians with higher integration had lower odds of using a manual toothbrush as compared to an electric toothbrush or use of both [OR = 0.86(95%CI:0.76;0.97)]. Highly integrated Indians had lower odds of consuming Indian sweets than lower integrated Indians (OR = 0.91; 95%CI:0.86;0.97). Indians with higher integration had 1.15 times (95% CI:1.03;1.29) higher odds of visiting a Dutch dental professional than visiting a dentist in both places (India and the Netherlands). No significant association was found between discrimination and the three outcome variables.ConclusionIntegration is positively association with self-reported oral health outcomes among the Indian migrants. Measure to improve integration among Indian migrants may help to promote healthy oral health behaviours and improve their oral health care utilization

Promoting parenting strategies to improve tooth brushing in children: Design of a non-randomised cluster-controlled trial

Background: Tooth brushing with fluoride toothpaste is a key recommendation in evidence-based guidelines for caries prevention. Parents generally have sufficient knowledge to practice tooth brushing for their child, yet many experience barriers to actually implement the behaviour. Common barriers are associated with difficult child behaviour, stress, poor family organisation and management of routines. These underlying determinants of tooth brushing behaviour should be addressed in caries-preventive interventions. The 'Uitblinkers' intervention is a semi-structured interview method developed for oral healthcare professionals (OHPs), with the aim to improve the practice of twice daily tooth brushing in children. The interview method focusses on 1) identifying parents' barriers to tooth brushing, and 2) promoting parenting strategies (related to tooth brushing) to tackle the identified barriers. The intervention applies principles from learning theory, including stimulus control, operant conditioning and authoritative parenting. This paper describes a study protocol to evaluate the effect of the intervention. Methods: This non-randomised cluster-controlled trial will be conducted in 40 general dental practices in The Netherlands. Intervention practices will implement the intervention in addition to care as usual, while control practices will only provide care as usual. From each dental practice, a random sample of 3 to 4-year-old children will be recruited. The intervention consists of three sessions between an OHP and parent, in which parenting strategies for identified barriers are discussed. The primary study outcome is children's dental caries experience after 24 months. Secondary outcomes include parents' self-efficacy in brushing their children's teeth, tooth brushing frequency in children and children's dental plaque scores. Differences in outcomes between the intervention and control group will be assessed using logistic and negative binomial regression. The feasibility of the intervention will be assessed through process evaluation. Discussion: Findings of this study will ascertain whether promoting parenting strategies is a successful method to improve tooth brushing in children and to prevent childhood dental caries in a clinical dental setting. Trial registration: This trial is registered with the Netherlands National Trial Register (registration date: 7 September 2018; trial registration number: NTR7469).</p

Improving Toilet Usability and Cleanliness in Public Schools in the Philippines Using a Packaged Operation and Maintenance Intervention

This study evaluated the impact of packaged interventions for operation and maintenance (O&M) on the usability and cleanliness of toilets in public schools in the Philippines. In this cluster-randomized controlled trial, the divisions of Roxas City and Passi City were randomly assigned to the intervention or control group. Schools in Roxas City (n = 14) implemented the packaged O&M interventions; schools in Passi City (n = 16) formed the control group. Outcome variables were toilet usability-defined as accessible, functional and private-and toilet cleanliness, measured using the Sanitation Assessment Tool (SAT) and the Cleaner Toilets, Brighter Future (CTBF) instruments at baseline and at four months follow-up through direct observation of school toilets. SAT results showed that intervention schools had a 32.0% (4.6%; 59.3%) higher percentage of usable toilets than control schools at follow-up after full adjustment (p = 0.024). CTBF results found a similar result, although this was not statistically significant (p = 0.119). The percentage of toilets that were fully clean was 27.1% (3.7%; 50.6%) higher in intervention schools than in control schools after adjustment (p = 0.025). SAT results also showed an improvement in cleanliness of toilets in intervention schools compared to those in controls, but this did not remain significant after adjustment. The findings indicate that the additional implementation of O&M interventions can further stimulate progress towards reaching Water, Sanitation and Hygiene service levels aligned with the Sustainable Development Goals

Dental caries and externalizing behaviour problems in a high-risk child population

The aim of this study was to assess the association between externalizing behaviour problems and dental caries in children. A further objective was to explore direct and indirect pathways between sociodemographic factors, family functioning and parenting factors, oral health behaviours, externalizing behaviour problems, and dental caries using structural equation modelling. Cross-sectional data were collected on 251, 5- to 8-yr-old children from a paediatric dental practice in the Netherlands. Children's decayed, missing, and filled primary teeth (dmft) scores were obtained from their dental records. Validated self-report questionnaires were used to collect sociodemographic, behavioural, and family-related data. Externalizing problem behaviour was significantly associated with a higher dmft score [incidence risk ratio (IRR) = 1.19; 95% CI: 1.06–1.34], but this association did not remain significant after adjustment for sociodemographic factors (IRR = 1.11; 95% CI: 0.99–1.26). A valid path model was presented after applying some modifications. Findings from the model suggest that it is plausible that child behaviour problems are directly associated with dental caries via toothbrushing behaviour. The model also provided support that maternal education level, the restrictiveness and warmth of parenting, and the communication of the family, play an indirect role in the association between children's externalizing behavioural problems and dental caries experience